UC Care

What You Need to Know

Designed especially for UC employees and retirees not enrolled in Medicare, UC Care (administered by Anthem Blue Cross) offers two tiers of in-network coverage: UC Select and Anthem Preferred.

 

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How it Works

See the plan comparison chart [PDF] for more coverage details.

Three tiers of coverage: Your cost for care is based on where you receive services.

  • Tier 1: UC Select. Available only in California. Features no deductible and set copays for most covered services when you get care from UC physicians and health centers and some other select providers. Every campus — even those without a UC health center — has access to UC Select providers.
  • Tier 2: Anthem Preferred. Offers a wider range of providers and facilities, with access to more than 62,000 providers statewide. You must meet an annual deductible, and then the plan pays most of the cost of services received.
  • Tier 3: Out-of-network. You can also choose to receive care from out-of-network providers. However, your costs will be significantly higher, and you’ll have to file claims. See the plan comparison chart [PDF] for more details about your cost for out-of-network care.

You can also choose to receive care from out-of-network providers. However, your costs will be significantly higher, and you’ll have to file claims. See the plan comparison chart [PDF] for more details about your cost for out-of-network care.

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Did you switch from the UC Health Savings Plan to another medical plan?

No-Cost Preventive Care

Preventive care, including services such as screenings, immunizations and exams for you and all covered family members when you see an in-network provider. (Out-of-network preventive care covered at 50% after the out-of-network deductible.) Learn more about covered preventive care services.

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What You Pay for Care

Deductible

  • UC Select providers: $0
  • Anthem Preferred providers: $500 (for individual coverage) or $1,000 (for family coverage)
  • Out-of-network provider: $750 (for individual coverage) or $1,750 (for family coverage)

Cost of care:1

  • UC Select providers: $20 copay for most office visits and other outpatient services. 
  • Anthem Preferred providers: After your deductible of $500, you pay 30% of the cost of most covered services; there is no deductible for preventive care
  • Out-of-network provider: After your deductible, you pay 50% of the cost of most covered services

Out-of-Pocket Maximum

This limits the amount you’ll pay for covered services during the year. After you meet the out-of-pocket maximum,1 Anthem pays 100% for most covered medical services and Navitus pays for 100% of most prescription drugs, for the rest of the year.

  • UC Select providers: $6,100 (for individual coverage) or $9,700 (for family coverage)
  • Anthem Preferred providers: $7,600 (for individual coverage) or $14,200 (for family coverage)
  • Out-of-network providers: $9,600 (for individual coverage) or $20,200 (for family coverage)

See the plan comparison chart [PDF] for more coverage details.

1. UC Select/Anthem Preferred deductible and out-of-network deductible and out-of-pocket maximums do not cross-accumulate (i.e., they are separate and do not count toward each other). In-network (UC Select and Anthem Preferred) medical and prescription drug out-of-pocket copay maximums do count toward each other.

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No Surprises

Did you know that if you receive emergency care or are treated by an out-of-network doctor or specialist at a hospital or ambulatory surgical center in your plan’s network, you are protected from surprise billing?

Learn more on the Anthem member portal at anthem.com.

Behavioral Health

You and your covered family members can use behavioral health benefits for sessions with counselors, psychologists or psychiatrists for mental health services and substance abuse treatment. If you need help finding a provider and booking and appointment, call Accolade at (866) 406-1182 Monday–Friday, 5 a.m.–8 p.m. PT. You can also speak to a therapist or psychologist virtually through Accolade Care Telehealth and Virtual Visits.

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Prescription Drugs

Your prescription drug coverage includes medications that are part of the Navitus formulary [PDF]. Log in to the Navitus member portal for a personalized view of your coverage and to preview drug costs, search for pharmacies, see your benefits, and view the Navitus formulary. (Prospective members can use these features on the unsecured Navitus portal.)

Download the Navitus App

The Navitus app offers mobile access to your digital ID card to view drug prices, find local pharmacies, and more.

iPhone   Android

 

Retail preferred network pharmacies: Fill up to a 90-day supply through UC participating pharmacies and the Navitus national network of preferred retail pharmacies, including Costco, CVS, Walgreens, Walmart, Safeway/Vons and more. Log in to the Accolade digital member portal to view the complete list of network pharmacies and find one near you.

  • Tier 1 (preferred generics and some lower-cost brand: $5 (30-day supply) or $10 (90-day supply)
  • Tier 2 (preferred brand products and some high-cost non-preferred generics): $25 (30-day supply) or $50 (90-day supply)
  • Tier 3 (non-preferred products, including some high-cost non-preferred generics): $40 (30-day supply) or $80 (90-day supply)
  • Tier 4 (specialty): 30%, up to $150 maximum (30-day supply)
  • Drugs covered by the Affordable Care Act: $0, including contraceptive drugs and devices, over-the-counter smoking cessation products and prescription drugs, and diabetes supplies (excluding syringes, needles and non-formulary test strips).

At non-preferred pharmacies, you'll pay $15 for Tier 1, $75 for Tier 2, and $120 for Tier 3 medications. Out-of-network pharmacies, you pay 40% of the allowable cost.

Mail order: Fill up to a 90-day supply of maintenance medications (those taken on an ongoing basis to treat chronic conditions like asthma, diabetes, high blood pressure and high cholesterol) for the cost of two copays through the Costco Mail Order Pharmacy. (You do not need to be a Costco member.) Start a new prescription and request refills online or use the mail order form [PDF], and your prescription will be delivered to you by mail. Learn more about how to set up your online account and order through mail order [PDF].

Specialty medications: You can fill prescription drugs used to treat complex conditions through either Lumicera Health Services or select UC pharmacies [PDF]. To get started with Lumicera, visit the website or call them at (855) 847-3553, or work with your provider to use a UC pharmacy. Lumicera offers free delivery to your home or other locations.

Money-saving options:

  • Tablet splitting: Buy fewer tablets by breaking a higher-strength drug tablet in half to deliver the same prescribed dose as a full tablet. For medications that can easily be cut in half without compromising efficacy, you can save up to 50% on out-of-pocket costs by having your doctor write a prescription for double the strength (e.g., 20 mg instead of 10 mg) and simply splitting the tablets in half.

Coverage restrictions:

  • Brand-name drug penalty: When a generic drug is available and you or your physician chooses the brand-name drug, you must pay the tier 3 (non-preferred) copay plus the difference between the cost of the brand-name drug and the generic equivalent. If a prior authorization is approved for a medical necessity exception, you will pay the Tier 3 (non-preferred) cost.
  • Prior authorization: Generally, your doctor must show that a particular drug is medically necessary. You or your physician will need to get approval from Navitus before the prescription can be filled. Log in to the Accolade digital member portal to learn more about prior authorization.
  • Quantity limits: Taking too much medication or using it too often isn’t safe and may even increase your costs. If you refill a prescription too soon or your doctor prescribes an amount higher than recommended guidelines, the Navitus pharmacy system will reject your claim. If your doctor believes your situation requires an exception, the doctor can contact Navitus to request prior authorization review.
  • Step therapy: In some cases, if your doctor prescribes a more expensive drug to treat your medical condition when a lower-cost alternative is available, Navitus requires you to first try the lower-cost drug before it will cover another drug for that condition. This includes medications used to treat ADHD, diabetes, high cholesterol and multiple sclerosis.

What is a Formulary?

A formulary is an extensive list of safe, effective medications covered by a health plan. Every pharmacy benefit manager (Navitus, for the UC PPO plans) uses its own formulary and it changes over time as new drugs enter the market and brand-name patents expire. Generally, if drugs aren’t on the formulary, they aren’t covered by the plan.

The Navitus formulary [PDF] is divided into four tiers. The lowest-cost drugs (mostly generic) are in Tier 1. The highest-cost drugs (specialty) are in Tier 4.

What does this look like?

Say you are newly diagnosed with high blood pressure and your doctor prescribes atenolol/chlorthalidone to treat it. A quick scan of the formulary shows atenolol/chlorthalidone is a generic equivalent for the brand-name drug Tenoretic. It also classifies atenolol/chlorthalidone as a Tier 1 medication, so you know what you’ll pay.

screen shot of formulary update showing a drug moving to tier 1

The formulary also will show if any restrictions and rules apply, such as prior authorization, quantity limits or step therapy.

Before filling a prescription, first find out if the drug is covered. A quick search of the Navitus formulary will tell you. Download the Navitusplus app to have the formulary with you at the doctor’s office. If the drug the doctor recommends isn’t listed, you can look for alternatives in real time. If you don’t see the drug on the formulary, you or your doctor can contact Navitus Customer Care at (833) 837-4308 for help.

If there’s a generic version of a drug you are prescribed and your doctor or you choose the brand-name drug instead, you’ll pay a penalty.

Formulary Updates

July 2024

Drug NameChange Type
STRIVERDI RESPIMAT INHALERMove to Tier 2
SEREVENT DISKUS INHALERMove to Not Covered
FLUTICASONE DISKUS INHALERMove to Tier 3

FLUTICASONE PROPIONATE DISKUS INHALER 50MCG/ACT

FLUTICASONE PROPIONATE DISKUS INHALER 100MCG/ACT

FLUTICASONE PROPIONATE DISKUS INHALER 250MCG/ACT

Move to Tier 3
FLUTICASONE HFA INHALERMove to Tier 3
ORAVIG TABMove to Not Covered
TOLMETIN TABMove to Not Covered
TOLMETIN CAPMove to Not Covered
SOOLANTRA CREAMAdd to Tier 3
ivermectin creamAdd to Tier 1
NEXLETOL TABRemove Prior Authorization
NEXLIZET TABRemove Prior Authorization
REPATHA INJRemove Prior Authorization
REPATHA PUSHTRONEX INJRemove Prior Authorization
ivermectin tabRemove Prior Authorization
STROMECTOL TABRemove Prior Authorization
AUGTYRO CAPAdd to Specialty Tier
FRUZAQLA CAPAdd to Specialty Tier
OJJAARA TABAdd to Specialty Tier
TRUQAP TABAdd to Specialty Tier
ZURZUVAE CAPAdd to Specialty Tier

June 2024

Drug NameChange Type
OPILL TABAdd to $0 Tier
SIMLANDI INJAdd to Specialty Tier
RIDAURA CAPMove to Not Covered
VIIBRYD TABAdd to Tier 3
vilazodone hcl tabAdd to Tier 2
lithium oral solutionAdd to Tier 1
LOKELMA PAKMove to Not Covered
VYVANSE CAPAdd to Tier 3
VYVANSE CHEW TABAdd to Tier 3
ADDERALL XR CAPAdd to Tier 3
LATUDA TABAdd to Tier 3
COMBIGAN OPHTH SOLNAdd to Tier 3
BYSTOLIC TABAdd to Tier 3

May 2024

Drug NameChange Type
dextroamphetamine ER capMove to Tier 1
clonidine ER tabMove to Tier 1
dexmethylphenidate ER capMove to Tier 1
methylphenidate CD capMove to Tier 1
methylphenidate ER tabMove to Tier 1
METHYLPHENIDATE ER TABMove to Tier 1
methylphenidate ER tabMove to Tier 1
methylphenidate chew tabMove to Tier 2
methylphenidate solnMove to Tier 1
methylphenidate ER cap (RITALIN LA equiv)Move to Tier 1
methylphenidate ER cap (APTENSIO XR equiv)Add to Tier 2
MULTIVITAMIN/FLUORIDE CHEWMove to Not Covered
POLY-VI-FLOR CHEWMove to Not Covered
MULTI-VIT-FLOR CHEWMove to Not Covered
QUFLORA PEDIATRIC CHEWMove to Not Covered
lamotrigine ODTMove to Not Covered
LAMICTAL ODTMove to Not Covered
lamotrigine ODT titration kitMove to Not Covered
LAMICTAL ODT TITRATION KITMove to Not Covered
DICLOFENAC PATCH, FLECTOR PATCHMove to Not Covered
XOLAIR INJMove to Specialty Tier
XOLAIR INJ 150MG/MLMove to Specialty Tier
XOLAIR INJ 300MG/2MLMove to Specialty Tier
XOLAIR SYRINGE 300MG/2MLMove to Specialty Tier

April 2024

Drug NameChange Type
mifepristone tabMove to Tier 1
diltiazem ER capMove to Tier 2
VERAPAMIL SR CAP 360mg Move to Tier 2
INSULIN LISPRO KWIKPENAdd to Tier 3
INSULIN LISPRO JR KWIKPENAdd to Tier 3
QVAR REDIHALERAdd to Tier 3
ALVESCO INHALERAdd to Tier 3
BOSULIF CAPAdd to Specialty Tier
LITFULO CAPAdd to Specialty Tier
XDEMVY OPHTH SOLNAdd to Specialty Tier
SOHONOS CAPAdd to Specialty Tier
VANFLYTA TABAdd to Specialty Tier
MIEBO OPHTH SOLNAdd to Tier 2
XIIDRA OPHTH SOLNAdd to Tier 2
TYRVAYA NASAL SPRAYAdd to Tier 2
cyclosporine ophth emulsionMove to Tier 1
PROMACTA TABAdd Quantity Limit
PROMACTA POWDERAdd Quantity Limit
TAVALISSE TABMove to Not Covered

March 2024

Drug NameChange Type
XPHOZAH TABAdd to Tier 3
THALOMID CAPRemove Prior Authorization
ZEPBOUND INJAdd to Tier 2
octreotide injMove to Tier 1
carglumic acid tabMove to Tier 1
tadalafil tab (PAH)Move to Tier 1
ambrisentan tabMove to Tier 1
bosentan tabMove to Tier 1
pirfenidone capMove to Tier 1
pirfenidone tab 267mgMove to Tier 1
pirfenidone tab 801mgMove to Tier 1
tiopronin tabMove to Tier 1
tetrabenazine tabMove to Tier 1
vigabatrin tabMove to Tier 1
vigabatrin powder packMove to Tier 1
vigadrone powder packMove to Tier 1
miglustat capMove to Tier 1
deferasirox tab 90mg, 360mgMove to Tier 1
deferasirox granules packetMove to Tier 1
deferasirox tabMove to Tier 1
deferiprone tabMove to Tier 1
trientine capMove to Tier 1

February 2024

Drug NameChange Type
SUFLAVE SOLNAdd to Tier 2
TRULANCE TABAdd Quantity Limit
MOTEGRITY TABAdd Quantity Limit
erlotinib tabAdd Quantity Limit
erlotinib tab 25mgAdd Quantity Limit
gefitinib tabAdd Quantity Limit
IRESSA TABAdd Quantity Limit
BRIXADI SOLNAdd to Specialty Tier
XALKORI CAPAdd to Specialty Tier
ROZLYTREK PAKAdd to Specialty Tier

Infertility Support

The journey to parenthood is not always easy. If you are struggling to conceive, WINFertility is here to help.

UC families enrolled in the Anthem UC Care, HSP, and CORE medical plans are provided a 2-cycle lifetime maximum benefit toward eligible expenses related to fertility treatment and related fertility medications. Coverage includes IVF, GIFT, and ZIFT coverage with 50% coinsurance (after deductible), up to a combined limit of two treatment cycles per lifetime, per member.

The benefit also includes artificial/intrauterine insemination (IUI) cycles, assisted reproductive technologies (ART), and related services as well as infertility specialty medications. It does not cover expenses for surrogacy, fees associated with surrogacy or expenses for procuring donated oocytes or sperm.

All fertility services are subject to medical necessity and prior authorization by WINfertility, which will also provide a range of support services.

What You Can Expect

WIN will help you better understand your options so you can maximize your benefit and choose the best course of treatment. More importantly, WIN knows this can be an extremely stressful and emotional time in your life. We are here to support you through every step of your fertility journey.

  • 24/7 access to WIN’s Nurse Care Managers for emotional guidance and support
  • Assistance in selecting a high-quality, in-network provider based on your individual treatment needs 
  • Expertise in understanding complex information and decisions regarding infertility causes, testing and treatment option success rates and risk
  • Guidance to help increase the efficient use of hormonal medications to avoid wastage and over-stimulation
  • Education on your pharmacy dosing usage, storage, and medication side effects and also assistance in maximizing your infertility medication benefit

WINFertility will assist you in selecting the right provider and navigating the system, your care and benefits. Working together with your health plan network of doctors and pharmacies, we provide you with total support and coordination of care. WIN has you covered!

What It Costs

After any applicable deductible, you pay 50% coinsurance for each treatment cycle. (Maximum of two combined cycles per lifetime for each covered member.) Your costs do not count toward the plan’s out-of-pocket maximum.

Get Started

For benefit details and eligibility, contact WINFertility at (877) 451-3077, or visit managed.winfertility.com/universityofcalifornia. Service team members are available Monday–Friday 6 a.m.–4:30 p.m. PT. And download the WINFertility Companion app from Google Play or the App Store to take advantage of your benefits on the go. (App code: UCA23.)

For more details, see the WINFertility flyer [PDF] and detailed coverage information [PDF].

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Coverage for COVID Testing

Provider-ordered tests: PCR testing is covered based on your plan’s benefits. You pay 30% of the cost after the $500 (individual coverage)/$1,000 (family coverage) in-network deductible.

Over-the-counter (OTC) tests: The plan covers up to 8 OTC tests per month. You’ll need to pay out of pocket and submit a claim form for reimbursement. Complete sections 1 and 2 of the form and sign where indicated.  Mail the claim form and your receipts for the OTC COVID tests purchased to Anthem Blue Cross, PO Box 60007, Los Angeles, CA 90060-0007. Claim processing can take up to 45 days. If you do not receive your reimbursement after 45 days or have any questions about your submission, contact Accolade at (866) 406-1182 for help.

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Find Care

The UC PPO plans give you a range of options to get care when you need it—from in person to virtual care (telehealth), and urgent care and emergency services through University of California Health Providers, the Anthem provider network, and Accolade Virtual Care and 2nd.MD. (Your primary care doctor and specialists may also offer virtual appointment options. Contact their office for more information.) You’re even covered when you’re traveling out of state or out of the country. Find the right care for your need.

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Referrals and Prior Authorizations

Some specialists — and specialty treatment centers (like nephrology or infusion) — may require a referral from your primary care doctor or prior authorization from Accolade before you can make an appointment. When scheduling an appointment, call Accolade at (866) 406-1182, Monday–Friday, 5 a.m.–8 p.m. PT to ask if a preservice review or precertification is required prior to your initial visit.

Certain services, such as a planned surgery with an overnight hospital stay, require prior authorization from Accolade. If you have a procedure scheduled or a condition that will require treatment, you may need a preservice review. For assistance, call Accolade at (866) 406-1182, Monday–Friday, 5 a.m.–8 p.m. PT.

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Filing Claims

Medical and Behavioral Health

When you see in-network providers, there are no claim forms to fill out. Your provider handles all the paperwork.

If you see an out-of-network provider for medical or behavioral health services or use an out-of-network pharmacy, it's up to you to submit a claim for reimbursement for services received or prescriptions.

The easiest way to file an out-of-network claim is to start with Accolade. Call (866) 406-1182 (Monday–Friday, 5 a.m.–8 p.m. PT) or visit the digital member portal. Accolade will direct you to the correct forms and answer any questions you have.

If you prefer, you can file out-of-network medical and behavioral health claims directly with Anthem through the Anthem member portal or the Sydney Health app. Download it through the App Store or Google Play.

Pharmacy

When you fill prescriptions at Navitus network pharmacies, there are no claim forms to fill out. Your pharmacy handles all the paperwork. If you use an out-of-network pharmacy, it's up to you to submit a claim for reimbursement for services received or prescriptions. The easiest way to file an out-of-network claim is through the Navitus member portal.

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Get Help

For questions about medical coverage, claims, finding providers and more, start with Accolade. Call (866) 406-1182 (Monday–Friday, 5 a.m.–8 p.m. PT) or visit the Accolade website.

For questions about prescription drug coverage and costs, call Navitus Customer Care at (833) 837-4308 or visit the Navitus member portal.

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Anthem Blue Cross Life and Health Insurance Company is the claims administrator for UC PPO Plans. On behalf of Anthem Blue Cross Life and Health Insurance Company, Anthem Blue Cross processes and reviews the medical, pharmacy and behavioral health claims submitted under the PPO plans. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Navitus is an independent company providing pharmacy benefit management services on behalf of the University of California for the PPO plans. Accolade is an independent company providing benefits advocacy services on behalf of the University of California for the PPO plans. Health Net is the claims administrator for the UC Blue & Gold HMO. Health Net processes and reviews the medical, pharmacy and behavioral health claims submitted under the UC Blue & Gold HMO. All plan benefits are provided by the Regents of the University of California. The content on this website provides highlights of your benefits under the UC non-Medicare PPO Plans plans and the Blue & Gold HMO. The official plan documents and administrative practices will govern in any and all cases.